A (nother) fantastic save! (long, a bit technical, surprise ending)

First of all, it’s fantastic to see James Hinchcliffe on the mend. As the story developed, we slowly were made aware of just how bad things had actually been. And now we’re told that he received 14 units of blood. This deserves some background, in order to fully understand just how well things worked for James . . . and draw some conclusions about how things are.

Even intuitively, hearing the number FOURTEEN PINTS is massive. Remember, James’ normal blood volume is probably (to simplify a bit) about 5 liters (for the english unit addicts, a quart is just about a liter). And a unit of red blood cells is about 400 ml. That means that his entire blood volume (5.6 liters to be exact) was replaced, presumably in the first 24 hours after admission. In trauma circles, that’s the standard definition of “massive transfusion”; this definition is not sterile, as it has important implications for management.

First, a few details.

Unlike what was headlined in some of the posts, the 14 units of blood were not administered BEFORE arriving at the hospital. There are several reasons for this (we will see the most medically relevant below), but the most practical is that this quantity of blood is NEVER available before getting to a hospital. The infield medical center at the IMS almost certainly has two to four units of blood (O negative, more later), but from there to the hospital, no blood would be available. More importantly, early transfusion of significant amounts of fluid are no longer standard protocol for massive bleeding.

The lovely tradition of drivers having their blood groups on their overalls is just that – a lovely tradition. No one, repeat NO ONE, will EVER EVER EVER be transfused based on some embroidered letters on his overalls. Ever. Period.

Let’s talk in some depth about just what and why the Holmatro team, and then the evac team who took James to the hospital did and didn’t do. First, some background.

Until very recently, the dogma in terms of taking care of trauma victims was to follow the “A B C” sequence. Life-threatening problems were dealt with in a very specific order. Problems with maintaining an open Airway were managed before problems with the Breathing, and only then were Circulatory derangements dealt with.

In terms of the circulation, by far the most common problem in trauma patients is hemorrhage. Blood loss causes a drop in the heart’s output, which in turn causes the various tissues of the body to be hypoperfused. This means that they receive too little oxygen and nutrients to maintain normal function. If this situation lasts, it is called hypovolemic (too little volume) shock. If this shock state lasts too long, it becomes irreversible; at that stage all attempts to save the patient are futile.

Advances in military medicine, notably during the Vietnam war, led to the idea of early and aggressive fluid replacement in shocked trauma patients. Intuitively this made perfect sense – since the primary problem was a deficit in circulating volume, restoring that volume (initially with relatively cheap and easy to store salt solutions) should allow cardiac output to trend upward, providing tissues with better nutritive perfusion.

This, in fact, is what is still taught in most mainstream trauma courses. After attending to the A and B parts of the protocol, we are told to rapidly begin infusing large quantities of fluid into shocked trauma victims.

The problem is, not only does this not work, but it actually makes things worse.


Once again, some visionary physicians, working in almost war-zone conditions (ok, Houston, Texas to be exact), followed by the conflicts of the 2000s, have taken the received wisdom and turned it on its head.

First of all, the A B C sequence is being, slowly but surely, revised. It is clear that with certain injuries (think IEDs, think suspension elements ripping up a major artery in the thigh), massive arterial bleeding will kill a patient within scarce minutes, usually even faster than loss of airway opening. This has led some to propose a newer, more time-relevant acryonym: MARCH. This corresponds to Massive hemorrhage, Airway, Respiration, Circulation, Head injury.

Remember Alex Zanardi’s horrible accident in Lausitz in 2001? Well when i title this post “another”, that’s the other save to which I’m referring. Both in Germany (kudos again to Terry Trammell and Steve Olvey), and at Indy last month, the rescue teams concentrated basically all their efforts on what we call “exsanguinating hemorrhage” – commonly known as the patient bleeding out.

The second reversal of “standard” trauma care is rather less intuitive, but incredibly important.

While the idea of rapidly restoring a normal circulating volume (again, using clear fluids) would appear to make physiologic sense, studies done both in civilian penetrating trauma, as well as the military’s amazing database show that it is plain wrong (the lessons from this database will save tens of thousands of lives over the next decades; this being one of the most significant and lasting legacies of the conflicts in Iraq and Afghanistan).

When we look at two groups of trauma victims in hemorrhagic shock, one of which receives early and aggressive fluid resuscitation, while the other receives almost no fluid (UNTIL THE SURGEON HAS STOPPED THE BLEEDING, meaning that resuscitation is not ignored but delayed), we see a very significant difference in outcome. And surprisingly, it’s the group who is “allowed” to remain shocked (again, and crucially, until surgical bleeding control is obtained) who do considerably better.

Why would this be?

There are a number of hypotheses, all of which certainly contribute to the better outcome:

  • Restoring circulating volume with clear fluids does not contribute to the oxygen carrying capacity of blood, and, importantly, dilutes the clotting factors so vital to stem the bleeding by natural means
  • Increasing the blood pressure likely makes the tenuous blood clots that DO form less likely to stay in place, increasing bleeding
  • Even when using warmed fluids (and this can be quite hard to do, especially in the pre-hospital environment) massive infusion of clear fluids will usually make the patient hypothermic. The thing is, our coagulation system is exquisitely temperature sensitive. It begins to fail, miserably, when temperature gets below around 35°C, a temperature that is all too “normal” in shocked trauma patients.

Another crucially important element that has come from study of the military’s experience in recent conflicts has to do with not just WHEN we replace lost volume (as soon as surgical control is obtained), but WHAT we replace it with.

When a blood donor give a pint of blood, that pint is almost immediately fractionated. The red blood cells are packaged separately (this is the fraction most often needed by patients who are anemic from various causes), with the plasma (it’s here that we find most of the coagulation factors) and platelets (tiny cell fragments vital in the coagulation process) packaged separately.

Until recently, it was felt that shocked trauma patients mainly needed red blood cell transfusions; it was thought that the need for plasma and platelets was relatively rare. In fact, when I did my residency, we were taught specifically that plasma was NEVER to be used “simply” to restore circulating volume…ever.

Well once again, what seems clear and logical turns out to be wrong. In fact, hemorrhagic shock almost immediately induces problems with the coagulation system. And the faster and more aggressively these problems are treated, the better the patient does. So much so that in state of the art facilities, the policy is that in the shocked trauma patient, the FLUID OF CHOICE for restoring volume is . . . you guessed it . . . plasma.

Enough background. Lets look at what the Holmatro team no doubt did, and how they kept Hinch alive long enough for the surgeons to save him.

There is no doubt that at the scene they were confronted with exsanguinating hemorrhage. Their first priority then was to get James out of the car, and to stop the bleeding, even temporarily. If the site of the bleeding was far enough down the thigh to allow use of a tourniquet, they certainly applied one, high and tight. If it was higher, precluding use of a tourniquet, they used modern wound dressings that contain substances that induce a powerful local formation of blood clots (called “hemostatic dressings”). In fact, they likely used both.

(This is another reversal in “standard” practice. It is still taught that tourniquets are last resort items. In fact, with exsanguinating extremity bleeding, they are the FIRST resort. Terry understood this intuitively with Alex in Germany, but it has not -yet – become the new normal. Once again, thanks to the military trauma docs for this.)

The Holmatro guys no doubt put in a few fat IV lines, but only infused enough fluid to keep Hinch (barely) alive, for fear of creating the situation I referred to above. They also probably gave him any of the O neg (universal donor) blood available from the infield med center. In addition, they certainly administered tranexamic acid, an old drug that “boosts” the coagluation system and has been shown to dramatically reduce mortality from hemorrhagic shock.

Then then prioritised evacuating Hinch to the hospital, and, crucially, made sure that there was an operating room ready for him, and that the necessary blood products were prepared. Once admitted, once the surgeons got control of the bleeding, the anesthesiologists began to transfuse. Not just red blood cells, but also massive amounts of plasma and platelets too. In fact, the ratio was probably pretty close to 1:1:1.

Make no mistake about it – only the knowledge, skill and teamwork of the Holmatro team at the scene made it possible for Hinch to get evacuated alive. They deserve massive credit for this. I sure take my hat off to them.

Now for the surprise.

American racing is organised more along the lines of just a few teams, who travel with their respective championships and thereby gain tremendous experience working with each other, training with each other, and staying current with best practice guidelines.

In F1, for a number of reasons, each circuit fields what should be an autonomous team. The FIA Medical Delegate and Medical Rescue Coordinator are only there, nominally, to provide liaison, coordination, and to confirm that regs are followed.

Long story short? Of the 20 races of the season, at best five to seven of these “autonomous” teams would be capable of saving James, had that accident happened at an F1 event. These are the teams that are mature, stable, experienced, and well led. And it’s not always the ones you’d think of that are up to the task.

There are a number of reasons for this, not least of which are high turnover in teams, lack of training, and lack of team member participation in prehospital trauma care in the “real world”. This is not new. When I was involved in F1 I continually trumpeted this fact to the hierarchy. Given that a permanent FIA team attending all races is just not realistic, I constantly pushed for more intensive simulation based training. The hierarchy found it politically inexpedient to deal harshly with the local Chief Medical Officers whose lack of leadership contributed to this. Remember, it’s the national federations who go on to vote for the FIA president.

Don’t get me wrong – the Medical Rescue Coordinator is present at every race, and is a massively experienced trauma doctor, fully equipped both in terms of knowledge, skills, equipment and leadership. And even at the majority of circuits where the local team would not be able to handle an accident as dramatic as James’, he has at his disposal sufficient “manual labor” to get the job done. That said, one must not labor under any illusions. If we imagine the same accident at every race of the season, the outcome will vary, sometimes dramatically, depending on where we are.

While the solutions to this are not simple (or cheap, no doubt), they do exist. All that’s necessary is the will and leadership to get the job done, and to improve the standards everywhere. And of course, the “knock-on” effects of such a commitment, both in terms of “lower” series as well as in trauma care in general, can’t be ignored.

Thanks for your patience.

70 thoughts on “A (nother) fantastic save! (long, a bit technical, surprise ending)

  1. Dear Prof. Hartstein, dear Gary,

    As a colleague and racing driver I have read this blog post with great interest. Usually I’m a silent reader, but this time I felt the urge to comment.
    You pointed out some very interesting strategies in the approach to patients with severe motorsports injuries and resuscitation strategies. I have always been educated with the ATLS principles. And although it is a good course, it is treated a bit like a ‘holy grail’ in the Dutch system. I’m not a believer in holy grails, so I liked your criticism on it.
    The MARCH approach I did not know about, as well as the advantage of ‘delayed resuscitation’ above early fluid replacement (unless you mean the principle of ‘permissive hypotension’). I’ve done some Pubmed’ing to find out a bit more, but I could not find what I was looking for. I was wondering if you could point me towards the studies you mentioned or some other good literature regarding the topic.

    Thank you in advance.
    Best regards,

    • Hi Max, and sorry for taking literally forever to get back to you! I do indeed mean permissive hypotension, and used the terms interchangeably. The idea being that we accept significant temporary hypotension (provided basic criteria such as consciousness and a palpable radial pulse) are met to avoid what appear to be the significant down sides of using non-oxygen-transporting solutions to establish a target blood pressure.

      Although I’m no longer an ATLS instructor (my current practice, and my likely future career path do not involve trauma) but I hear that the newest edition now recommends just 1 l of crystalloid in a hypotensive trauma patient before moving on to blood and blood products. Better late than never, eh?

      • Hi Gary, no problem for the late response! I’m familiar with permissive hypotension. The border of what I accept is 90/60mmHg or loss of conciousness. Yes you are correct about the 1 liter crystalloids before moving on to blood products. Though you will be amazed how many ED’s are still using the 2 liter crystalloids. But regarding the MARCH principle, which I’m very interested in, but could not find any literature. Where does it come from? Because I’d like some further reading on it, just as an expansion of my knowledge. Is it a field expert approach that isn’t widely propagated in scientific papers? Because I couldn’t find any further reading on it.

        Best regards,

  2. The following may be of interest to some. It indicates that in some contact sports concussion is beginning to be taken more seriously.

    Looking at scrum caps which many rugby players now seem to wear – I learn it doesn’t afford much protection to head contact and concussion – they were designed to protect the ears:

    Research Paper published Feb 2009 https://www.ncbi.nlm.nih.gov/pubmed/19127196
    Padded headgear does not reduce the rate of head injury or concussion. The low compliance rates are a limitation. Although individuals may choose to wear padded headgear, the routine or mandatory use of protective headgear cannot be recommended.


    These are called soft shell head guards. So it seems Rugby will have to introduce a form of hard shell head-guard / cap if they want to protect against the possibility of concussive head blows.

  3. I really need to know what kind of car debris caused such a tradegy that claimed wilson’s life. In such circumstances we need to know that how fast this material hit the driver or how much metre it went high then hit the driver. How much weight is it? Can it be more stabilized such materials inside the car? It is very important. I know the result wont be change however we may have never ever again live through the same if we do the right things about the racing cars. I hope we learn more details about the accident..

  4. Just wanted to express my condolences to the family and friends of Justin Wilson. I knew the name but not the person. I know that motor racing is a lot safer than in the past. And racers know the risk but love racing and love speed. Some people need the buzz they get out of dangerous sports and activities, bungee jumping and jumping off tall buildings, bridges, cliffs – the adrenaline rush they need to make them feel alive. There just seems to have been a bout of fatalities in motor sport in recent years and motor sport accidents tend to be fatal.

  5. I’ve been watching some old Indycar races recently (back to early 90s), and Trammell/Olvey were in force then. Their experience is incredible. I’ve often thought on Marshaling grounds as well as medical, the IndyCar safety teams that travel to every race were an excellent idea. No matter who it is and where they are, they rock up and do their thing like clockwork. “Corner Workers” provide support. F1 needs this in my opinion – Cars and situations are getting to specialised for a volunteer to do once a year. That is not to insult the amazing job Marshals do – but it’s clear there is a potential disaster awaiting F1. It would be nice if it never happened.

    • The idea of a traveling team is indeed attractive. There are, however, political, diplomatic and legal constraints to doing something like this in the Formula 1 environment. Because of that, intensive education and repeated realistic simulation with the various local teams of the season would seem to me to be the best guarantee of quality care trackside.

  6. I have a general question about cervical spinal injury. Please excuse the fact that this question is o.t. to this specific thread ( if you erase– thanks for your time).
    I’ve heard that when someone has an injury at c5 and the cord is broken, cutting technology is to inject stem cells there in hopes of regrowth. Why don’t they simply transfer cord from the bottom of the cord?
    The cells are already differentiated and the injured party’s legs are already paralyzed. It seems like they should aim to regain arm movement rather than just leaving the unused spinal cord below to do nothing.

    • Hi Siara – sorry for the interminable delay in answering. First of all, if there are any experts in research trends in spinal cord injury out there, feel free to jump in!

      Your idea makes great sense. I’d only point out a few elements. It’s often thought that the spinal cord is basically cabling, connecting the processor with the output and input organs. This is a gross simplification. The spinal cord is an EXTENSION of the brain, and is rightfully part of the central nervous system. Considerable processing occurs both on the way up to the brain, as well as on the way down. This means that the wiring can tend to be extremely complicated. Simply “grafting” a segment of cord into the damaged area would seem to me to be very unlikely to allow the proper connections to be made.

      Secondly, the fact that the cells are already differentiated would not necessarily be a plus. It’s precisely because of the developmental flexibility of stem cells that they look to be a possible solution. Once the triggers for appropriate development AND architecture are understood, this may well be one of the best ways forward.

      • Further, the chemotactic signals, BMP’s, Sonic hedge molecules(what a name!) + other routing signals that were present when the spinal cord was developing (nurulation) in the embryo are missing in an adult human. The presence of stem cells alone would not allow for proper “wiring” of new spinal cord material.

        If all that happened was ends of spinal cord neurons were randomly joined by introducing stem cells (and to be honest even this is a stretch) all you would have done would be to replace a severed spinal cord with a seriously badly wired one. As Gary mentioned above the spinal cord has a lot of processing tasks related to pain, motor control, autonomic functions etc. Would having these systems go totally haywire be better for the patient?

  7. Not really a comment to the text, but anyway… Think that walnuts (inside) are so much like a brain. Left, right and middle stem…

  8. Came across the following on the BBC website today: http://www.bbc.co.uk/news/uk-northern-ireland-33404085

    “The worlds of medicine and motorcycling are mourning the loss of Dr John Hinds, who has died after a bike crash in Dublin. Dr Hinds worked as a volunteer medic at races across Ireland. Andy West reports. ”

    The video clip indicates he was an amazing human being, dedicated to safety in motorcycling racing in Ireland. He was a intensive care consultant and anaesthetist according to one of the reports. He died during a practice session for a motorcycling race in the Republic Ireland.

    More Information:

  9. Hi Gary,

    In light of the tragic accident of this past weekend in Laguna Seca, I was wondering if emergency response and medical support at motorcycling racing events generally follow the same protocls and procedures you describe on this blog? Or are the potential consequences of motorcycling accidents so different than what we see in 4 wheels racing that they would require a very different type of response?


    • The motorcycle medical folks largely practice the same way we do. Their environment is, as you point out, different from ours (they never have to deal with extrication, we don’t have to deal with shoulder humps interfering with cervical spine management), but the principles and organisation are largely interchangeable.

  10. Terribly sorry to hear of Jules’ death, it has been a gut wrenching 9 months for his family, friends and those of us involved in motorsports. Your article is a great distillation of modern thinking on primary casualty treatment. My own personal experience as a race official in the US allowed me to be involved from the days of hay bales and white pants to the modern days’ Holmatro team. During the 1st two F1 races at Long Beach we were besieged by drivers, team members and a few principles asking if there was any possible way we could affiliate with F1 and travel to all their events. They wanted everyone from Registration, Pit, Grid, Flag T&S, Fire/Rescue, to Starters. That’s how much they were impressed with the entire SCCA’s professional abilities and conduct. That said, racing in general still has a long way to go in training, skills development and critique. Oh, my neighbor is doing his internship here in Boston in your field, I’m going to pass this post on to him. Keep up your writing, it’s more valuable than you know. Cheers, Bill

  11. Excellent article, as so many have said.

    If you’d be willing and have time, have you considered reviewing the failed methods and experimental techniques you’ve covered here and in the past and making a book of it? A “how not to kill your patient” guide might help with safety on the track in the way you envisaged and might improve trauma care in general.

  12. I know it has been explained but if someone would do it again that would be great. What was the difference between the JB brain injury and the MS injury?
    Do we know if JB was on life support and the family decided to remove it? Why do some wake up eventually and others don’t after being in a long coma. MS did but JB and BKB did not.
    It has probably been explained over and over but when you reach a certain age….you tend to forget. 😉

    • Hi Mimi, my understanding from reading this site is that MS was/is minimally conscious by April whereas the other 2 didn’t ever reach this stage. I think that the only life support would be a feeding tube – we know that Jules was breathing by himself. In the UK it is legal to withdraw artificial feeding in a vegetative state but not in a minimally conscious state. The court has to decide not the family. I think it may be different in the US and other countries. I know that Bobbi Kristina has been moved to a hospice now and I suspect that her feeding tube may have been removed as doctors have told the family there is no hope of recovery.

    • Don’t know if i imagine this correctly, but i think MS has only certain parts of brain heavily injured on the outside, whereas JB has basically the whole brain injured internally. It’s probably debatable which of the two outcomes is “better” as they’re pretty much both horrible 😦

    • I think Jules “died” 9 months ago. Now his body has died. There was no suggest that there was brain death, but everything that made Jules, Jules, likely died 9 months ago.

  13. Hi

    Gary just read the very sad press release from Jules Bianchi’s father that he hasn’t improved and it sounded to me as if they were now debating whether to pull the metaphorical plug.

    Is this the outcome you expected from this sort of injury and is all hope of further recovery now realistically over?

    • I’ve no details on Jules’ case, but the vast majority of patients with persistent disorders of consciousness after trauma have completed their recovery by one year after injury. Mr. Bianchi is, tragically, quite correct on this point, which is, let’s remember, a statistical waypoint, not a guarantee of anything in any individual case.

  14. In the light of several very sad articles about Jules Bianchi this week, I wonder about the ‘showcase’ effect of good practice at high profile events and the effect of TV coverage. I know that Bernie was originally concerned about drivers dying on camera and I would like that the focus is not always on the immediate effects of any medical intervention but also the long-term consequences for everyone involved.

  15. Gary, thanks for this very interesting and informative article.

    After 30 odd years in engineering I am happy to admit that I’ve often thought “Oh, it’s obvious what I need to do” and then discovered that I was wrong and it wasn’t obvious at all and I then needed to do a much more careful analysis before coming up with a fix. Luckily for me the things I work on are not biological and don’t bleed out or expire from lack of blood/oxygenation.

    I keep thinking that what the top knobs in F1/FIA need is a Mr BigUglyBloke to apply appropriate persuasion when they do the wrong thing. Any chance of that happening d’you reckon?

    • Just seen that released data from the FIA suggests that decel in Jules’ crash could have been as high as 254g!

      I am amazed that such a force is survivable for any length of time.

  16. Gary, as always an excellent, well informed, article with a lot of information which, i find great for further research (as a non medical person with a big interest in medicine),,, i really enjoy reading your insights, please keep them coming.

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  18. Having read this post I was fascinated to see a BBC documentary ‘An hour to save your life’ yesterday featuring a cyclist who was bleeding to death from pelvic injury and they carried out REBOA at the scene. I think this is part of Prof Sid Watkins legacy as he was fundamental to the development of the Royal London Hospital’s helicopter emergency service. It’s a pity that standards at some F1 venues may now be lower than in central London for similar life threatening accidents.

    • Thanks for this Jane. Just need to point out that REBOA (resuscitative endovascular balloon occlusion of the aorta) is FAR from being standard therapy, and at this point should only be used in the context of methodologically robust clinical trials (this was no doubt the case for the victim you’re speaking about). Another example of an intuitively “obvious” technique that still has to prove its worth!

  19. Hi Gary,

    as you know I have always been concerned with the varient levels of care availible at an F1 event on track and paddock for the teams, but it does not stop there, I have similar concerns with a wide range of other FIA events. To which I did present to the FIA in Paris closed car working group, with Prof Sid Watkins and then head of safety Ian Brown. in that it is often clear that in some countries the rescue teams that are expected to extricate a casualty have very old hydraulic tools that will be ok, on a twenty year old scrap heap car, but up against a new vehicle technology car straight out of the show room would fail, let alone when they are up against an homologated race car.
    I made that presentation 10 years ago! has it got any better…
    when we look at the advancements in new vehicle techology and that of medicine and take into account the combination of how we manage the entrapped driver under a CABC or MARCH principle and the lethal triad approach in damage control resuscitation, with a designated paramedic lead team doing what they do best in a pre-hospital setting.

    But some counties ASN rather use a wide skill set range of Doctors that only have trauma experiances from attending ATLS type courses, and have no underline tacit knowledge from either being first on scene track side or directing from race control…..

    enforce, educate and engineer are the 3 E for preveneting and reducing vehicle related injury and deaths.

    • Hey Steve! Thanks for commenting – always wonderful to get feedback from one of the professionals I respect most!

      Agree fully about many of the teams fielded by ASNs basically being able to “tick the right boxes” as opposed to actually being able to handle the various problems and scenarios they might actually confront. The kind of training and commitment needed for that is quite massive, and costs money and time. This relates also to the qualifications of the folks working trackside. Turns out that after the “novelty” factor wears off, getting and retaining fully skilled and experienced professionals, willing to put in the time to stay current and actually advance with vehicle technology and medical science almost always involves PAYING THEM. Professionalisation of the medical/rescue teams at high-level events has always been a red-button issue, with promoters complaining of their high costs, etc.

      This has always shocked and disappointed me, as the same promoters have no problem spending fortunes on flowers and bubbly for their VIP suites. Paying for quality should be factored in from the get-go, and be considered one of the costs of doing business.

      In terms of trickle-down, this will always lag, but the speed and extent to which quality care reaches down to the grassroots will depend critically on a few things. Among these are the commitment the FIA and the ASN to make that happen (with all attendant implications in terms of time, cost, etc), to the skill and leadership of the medical component of the ASN’s medical commission and CMO, and to the express demand of the grassroots to receive modern quality care.

      Thanks again for jumping in, love to all!

  20. Doc —

    I don’t think that this issue has gotten any press, but my concern is this guy’s ability to come back from any head injuries. Certainly the interviews that I’ve heard doesn’t sound like the Hinch that I’ve interviewed / talked to?

    Prior studies indicated that anything over 50 G’s would cause brain injury problems for the driver. Hinch took 125 — and I note that the accelerometer was in his ear, so that’s what the brain got too. Hinch admitted that he doesn’t remember much of the first week after the accident.

    I recall that Dario Franchitti got out of his car for good after this third major concussion due to brain issues. And Hinch had a bad concussion a year prior at Indy’s road race at the start of May ’14, so this is at least #2.

    • You raise some very good points. It’s entirely possible that Hinch’s failing to remember anything is more due to the profound shock state (remember, by definition the organs, including the brain, are not adequately perfused when the vic is in shock) than to concussion per se. I also have some problems with the “fidelity” of earpiece accelerometers, as there are persistent problems with how they “couple” to the head.

      That said, it’ll be a year before he even tries to get back into a competition car, at which time he’ll be carefully evaluated and instructed as to the implications and ramifications of further episodes of MTBI.

  21. Just a quickie to thank you for taking the time to write what I’ve always found to be very measured, well-reasoned and informative articles. An increasingly rare thing these days, it can sometimes seem. I enjoy your posts, and appreciate your taking the time to write them. Cheers.

  22. It’s amazing that anyone can lose so much blood and still survive. I just wonder if this accident had happened anywhere where emergency services were far away and unable to get there for at least 15 minutes if the body has any kind of natural clotting mechanism to lose a leg and protect the brain to save a life. For instance is it possible that a bystander could put a tourniquet on (or even the person themselves) and as the blood volume was reduced could the bleeding slow down? I was reading yesterday about people trapped on the Smiler rollercoaster at Alton Towers. Emergency services were slow to get there (bystanders were taking pictures on mobiles instead of phoning 999) and there were reports of blood on the ground from massive leg injuries. Despite the fact that the worst injured has had a leg amputated and some people were trapped for around 4 hours everyone has survived.

  23. Have missed your writings Gary. Keep them coming. Thanks for making the effort to keep them technical and understandable at the same time. Also enjoyed your musings of the “new” middle east that you have found yourself in….

  24. The first media reports I read was Hinchcliffe had only sustained a fractured leg bone. After reading Gary Hartstein’s report, learned Hinchcliffe had in fact suffered a life threatening injury. Part of a wishbone suspension pierced through and penetrated his pelvis and the responding medical team got a hold of it. Awesome medical response. .

  25. Thanks for that useful insight. My husband and I travelled over to Toronto from the UK after seeing the F1 in Montreal. We were lucky to see Hinch up close twice and he was even walking gingerly. He had his legs out straight when in one of the golf buggies being ferried around. Amazing he is walking and he does seem to have lost weight but will hopefully be racing next year.
    I’m surprised cockpit intrusion by suspension struts hasn’t happened more often but Thank God it hasn’t! Love your blog Gary, please keep writing!

  26. Fantastic explanation! And thanks for the kudos! All safety/race medical teams here in North America pride ourselves in being able to deliver state of the art care, in less than ideal conditions/environments! Again, we love reading your articles here in Canada, and hope the dry desert air is still agreeing with you!

  27. Perfectly written piece that drew me in immediately. Once upon a time, a mechanic in Indy car racing. Post-racing career, now a nurse (long story).
    I salute the Holmatro Safety Team on their near-perfection response, and thank you for the very informative article that gives me better insight about the best response to these types of injuries.

  28. I just read about him. (I don’t follow Indy cars anymore) Only eight days in the hospital? That’s another miracle.
    I do not hope to ever see any details of the injury though. The little I’ve read firmly places his survival in the “miracle” category!
    Great article, too! The safety crews and medical personnel did a fantastic job.

  29. Amazing and extremely interesting article as always . Having been at the thick end of a major trauma losing an arm at the age of 6 it’s extremely fascinating to hear of some of the medical procedures and practices that take place during such an incident , mine occurring some 40 + years ago and in those days was a pretty serious accident and probably life threatening , but even then the skills and abilities of the trauma team almost definately saved my life as I’m sure they and yourself have done on many occasions since and will continually do so and for that I thank you all very much . Some people are given these amazing skills and the ability to save lives in terrible trauma situations and incidents …. What an incredible ability to have and what an amazing feeling it must be to walk away from an incident or from a theatre knowing you’ve done the ultimate thing and saved someone’s life !

    • My bleed out occurred 45 years ago, in hospital. I received 5 units of blood and 3 of plasma. My surgeon was freshly returned from Vietnam and at the top of his game, or I wouldn’t be typing this now. For all its tragedy war has done much to enhance our knowledge of trauma; the entire concept of the “golden hour’ is courtesy of Korea and Vietnam, and it has only been enhanced by Iraq and Afghanistan.

  30. Brilliant article. You brought up some really good points. I feel that the Halmatro safety team are the best in the world because although they operate in small teams, they are dedicated teams who know exactly what to do and know each other intimately. F1 maybe has 4 teams that know what they are doing and really only 2 people who intimately know each other. The Holmatro safety team are on the scene when needed very quickly and are effectively able to save someone life

  31. And you are thanking us for our patience! Holy cow. THANK YOU! What a terrific article. You answered a question I thought of concerning the likelihood of a positive outcome had the same penetrating injuries occurred in F-1 today. It seems like the luck of the draw in that case. Not too encouraging.
    An quick note to the use of tourniquets in the U.S. Military, as you know each combat soldier carries a tourniquet with them. At one point during the war in Iraq and the losses to IEDs were mounting, soldiers were prepositioning tourniquets high up on their extremities, arms and legs, in order to lessen the application times in case of amputation injury. I am told this did not last long as it was seen as being defeatist and not in keeping with the positive image the Bush administration wanted to project. Easy for them to say.
    Hope your new job and life over there is going well, and thanks again for spending the time to enlighten us all. Really good stuff.

    • I had tourniquets added to the list of required kit in intervention cars soon after Terry’s save. And one of our first accident simulation scenarios was exsanguinating hemorrhage from a leg injury, just to drive home the point

  32. highly instructive article as always. The first time I saw the accident I hadn’t realised how serious it was.
    Kudos for the medical team, no doubts.

    Just a curiosity. You mentioned that driver gets O neg blood if needed. Is it due to a chance of some kind of reaction, even with the ‘right’ blood? Or just a matter of logistics? Or any other reason?


    • When blood has to be transfused under emergency conditions, O negative is used because of the very small chance of a major hemolytic reaction, especially in people who have not been transfused before that.

  33. Excellent article Gary, thank you. Once again you have made the ostensibly opaque and arcane, lucid and clear. May I link your article (or copy and paste it, referencing you) to our ED Trauma team as a training tool? Training tools and articles are often very dry and are not read during breaks at work, whereas this article would very likely be picked up and consumed by a DR or Nurse if I can find the right forum.

    • Thanks! Of course you can reference/link/copy-paste. No worries. I’d assume most ER staff would be up-to-date with this stuff. But feel free to use it – it’s in the public domain!

  34. Gary, thanks for your astutute comments on the amazing survival of both James Hinchcliffe and Alessandro Zanardi. Unfortunately, INDYCAR is the sole American series that has this kind of on-call medical access, which began with the Trammell/Olvey CART/ChampCar traveling team that was initially formatted by Lon Bromley. The training exercises for the local medical adjuncts at each track have always been exceptional, as it’s impossible to have all the permanent staff one needs at most tracks. Indianapolis Motor Speedway, too, is far better equipped than, say, Barber Motorsports Park (just as a for-instance). The training, the intuitive nature of moth the EMS/physician staff helped to initially save James Hinchcliffe. His own will to live, to survive and to race again has allowed him to exceed his physicians’ expectations and today he is the on-site grand marshal of his hometown race in Toronto. A miracle? In many respects but as Hinch so aptly put it, “We racecar drivers are wired differently.” Thanks for making my pale with your insightful medical terms – as I was there at IMS I knew it was a Zanardi-like occurrence, but I never have known many of these details.

  35. Great post. As a long term practicing veterinarian, I’m always amazed at the advances and resources available to the human trauma teams. Thank the Lord for their skills!

    Sent from my iPhone


    • Among other things, it’s because we make war. But hats off to the military for their total commitment to evidence-based guidelines, their astonishingly powerful data collection, and the bravery of every doctor, nurse, and medic wearing a uniform.

  36. Always so interesting. Thanks doc. Let’s hope that we don’t ever have to see another example of this rescue happen in F1, or any other discipline, anytime soon.

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